Tuesday, November 18, 2008

Disclosure Wars: The Case of Goozner vs. Pies

Transparency has become all the rage in medical publishing these days, which is a good thing. A recent battle between the Integrity in Science Project website and the journal Psychiatric Times is a great illustration of some of the more complicated issues involved.

What makes this case especially interesting is that there is no “good versus evil” dynamic here. One on side of the ring is Merrill Goozner, a former business journalist who is the director of the Integrity in Science Project, part of the nonprofit organization Center for Science in the Public Interest. I know Merrill personally and can vouch for his ethics and passion for honesty in science.

Standing in the other corner is Ron Pies, M.D., a psychiatrist and editor-in-chief of Psychiatric Times. Ron and I are friends and colleagues, and he is one of the most thoughtful people I have met on issues of ethics. In fact, he invited to write this two part articleon conflicts of interest in psychiatry, which he published in Psychiatric Times two years ago, in November of 2006.

We have two fine individuals scrimmaging over an issue they both care deeply about. So what happened?

Here’s the sequence of events.

First, on August 1, Dr. Pies wrote this editorialin which he discussed Senator Grassley’s investigation of conflicts of interest, and announced that his journal would henceforth begin posting the financial disclosures of its entire editorial board.

Then, on September 2, Merrill Goozner posted this short piece on his Integrity in Science Watch in which he acknowledged Psych Times’ efforts at transparency but nonetheless added a little jab by claiming that Dr. Pies personally has industry ties, which is at odds with the recommendations of The International Committee of Medical Journal Editors' “Uniform Requirements for Manuscripts Submitted to Biomedical Journals,” which declares that “editors who make final decisions about manuscripts should have no personal financial involvement in any of the issues they might judge.”

In response to Goozner’s backhanded complement, in the current issue of Psychiatric Times there is an unusual commentary entitled “Setting the Record Straight.” It is unusual in that it is written by both Susan Kweskin, the journal’s editorial director, and by Dr. Pies, who is the editor-in-chief.

The gist of this article is that, in fact, Dr. Pies has accepted no money from drug companies since becoming editor in January 2007. When Dr. Pies wrote to Goozner to correct the error, Goozner’s response was that “We use a 5-year-look-back period for conflicts of interest. This is the same look-back period used by the Journal of the American Medical Association.”

Fair enough, responded Dr. Pies, but it seemed to him that Goozner has chosen JAMA’s particularly long look-back period to “single out specific editors-in-chief and their publications” for subtle accusations that they are allowing conflicts of interest to bias the content. Furthermore, Dr. Pies scolded Goozner for failing to contact him directly to find out if he, indeed, had conflicts of interest that would continue to be relevant to his current responsibilities.

Goozner has yet to respond to this latest installment of the drama.

So who’s right and who’s wrong? Both.

Goozner is right to be concerned about editors who have had recent financial relationships with companies related to their editorial work. While there is nothing magic about a five year vs. a one year look-back, it is probably true that editors who have received money relatively recently from a company are more likely to have their judgment affected than those who left the entanglements behind many years ago.

However, in his zeal to root out the rascals, Goozner went overboard and skipped some of his due diligence. Dr. Pies in particular was not the person to go after, and Goozner could have learned about his reputation for honesty by asking anybody in the field. Furthermore, Goozner claimed that Robert Freedman, editor in chief of the American Journal of Psychiatry, also has drug company ties, but in his slap-dash web search he linked to the wrong person: a “Robert R. Freedman, PhD,” who is a professor of psychiatry and obstetrics and gynecology at Wayne State University School of Medicine, and who has no connection to the Psychiatry Journal’s Robert Freedman. As it turns out, the “real” Dr. Freedman indeed has had some connections to pharma, but it’s not clear what they are, or whether they are ongoing—this was a confusing issue that I once tried to clarify in correspondence with Dr. Freedman, described in this blog entry.

Dr. Pies is right to be peeved about Goozner’s “broad brush approach to disclosure,” as he put it. I have certainly been guilty of this practice as well. The fact is that those of us involved in blogging and the media feel a constant pressure to publish something, and we really need to be more cautious about the claims we make.

On the other hand, Dr. Pies has chosen to edit a journal more dependent on drug company funding than most. Unlike JAMA and the American Journal of Psychiatry, Psych Times is a “controlled circulation” journal. This means that doctors don’t have to subscribe to get it. In fact, every month it is sent for free to over 40,000 psychiatrists. Just about every last dime of the journal's income comes directly from the pharmaceutical industry. Companies pay extremely high prices for their ads (here is the journal's rate card) precisely because the journal can guarantee that ads will be viewed by 40,000 sets of prescribing eyes. Furthermore, the parent company, CMP Medica, presides over a veritable industry CME empire, including the U.S. Psychiatric Congress, and produces industry supplements packaged with Psychiatric Times. (Dr. Pies has no editorial control over these supplements.) I reviewed one of these supplements last year, and found it to be a subtle advertisement for Bifeprunox, an antipsychotic made by the supplement’s corporate sponsors, Wyeth and Solvay. This is not to impugn Dr. Pies’ reputation, but rather to point out that he has an exceedingly challenging job of ensuring unbiased reporting in a journal that must, to a greater degree than many others, keep the drug companies happy to survive.

Bottom line: Watchdogs like Merrill Goozner (and myself) are crucial during a time when medicine is finally taking a close look at its relationships with drug companies. But we need to be careful not to take an indiscriminate shotgun approach in our investigations. On the other hand, there are some ethical editors like Dr. Pies who have decided to work within an industry-supported environment, but who are trying to keep their journals’ noses clean. May the Force be with us all!

4 comments:

therapyfirst
said...

Nice piece! Dr Pies and Ms Kweskin responded to my email about the editorial and were as respectful as you say.

This whole process in exposing our "peers" has been equally fascinating and repugnant to me. I just hope responsible people continue to call colleagues on questionable judgments as they are viewed. In the end, truth and directness will prevail if they are the attitudes practiced.

A clinical, nuanced stance doesn't play well in the world of political discourse. Public forums call for bold pronouncements, whereas in the office we (most of us, anyway) are more circumspect.

I've always thought it odd how readily public statements can be retracted, or dismissed as "misspoken." Yet this story illustrates how well-meaning people can overstate their case, and why it's valuable both to be bold, and to backpedal on occasion.

I am concerned about Dr. Carlat's implication that PT is the only journal that profits from ad dollars. The comment, "Dr. Pies has chosen to edit a journal more dependent on drug company funding than most" is misleading.

Clearly, all major medical publications are supported by advertising revenue. Controlled circulation is indeed the norm, with the exception of association journals which are paid as part of membership dues to the affiliated organization -- journals such as the ones Dr. Carlat has cited -- JAMA and American Journal of Psychiatry.

The point should be made also that non-association journals with controlled circulations are free to be more objective and controversial than society journals, as they are not tied to an organization and do not operate as a voice for the association's platform. There is definitely value in autonomy.

Finally, there are numerous examples within the pages of Psychiatric Times thatexemplify the journal's editorial integrity and fair balance. Two recent ones would be the news items in our November issue: "Atypical Antipsychotics No Better than Antipsychotics in Treatment Trial" and the piece on Bipolar Consensus Statement which makes reference to "insufficient data on atypical antipsychotics for bipolar disorder."

Articles such as these demonstrate how Psychiatric Times courageously reports on the full spectrum of news as it affects the specialty, regardless of whether it serves as positive or negative press for sponsors. This is the sort of responsible journalism that has won Psychiatric Times the respect and loyalty of readers over the past 25 years.

You make some good points. I give Psych Times credit for being one of the best of the controlled circulation journals for balanced reporting. In fact, as I mentioned in the posting, you stuck your neck out and published my articles on disclosure two years ago.

However, any editor of a controlled circulation journal is inevitably going to be looking over his or her shoulder at advertisers, and will refrain from being excessively critical of them. I think you'd agree that this is the reality of the job.

Regarding the CME supplements, I have found them, on the whole, to be subtly biased in favor of the sponsor's products. This, too, is an inevitable part of the industry-funded CME business.